spitting blood

[diverdown81]

my son and I went scuba diving saturday, and he went inverted (head down feet up) at about 10ft and possibly ruptured his ear drum. today he said he is now spitting up little clumps of blood. we were diving at the disney world epcot Nemo undersea adventure 6 million gallon tank with a 25 foot depth. any ideas? he has no insurance or job right now.

[ENTMD]

Thank you for taking the time to reply to my questions.

You have, perhaps unwittingly, made my point for me!  Your list of references, which include Wikipedia and other Google sources, are not the basis of evidence-based medicine.  As physicians, our standard of evidence needs to be of better quality.  I asked if you could provide placebo-controlled studies to support your liberal use of antihistamines for eustachian tube dysfunction.  These would be found using, for example, PubMed or simply searching through the core Otolaryngology journals.  They aren't there.  Because Google or Wikipedia said so should be meaningless to us.

Your statement that, "antihistaminics...reduce the nasal as well as congestion around the opening of the Eustachian tube"  is simply unproven.  This myth is commonly held by primary care providers, but to hear an Otolaryngologist perpetuate this is quite surprising!

Finally, antihistamines are not decongestants.  Perhaps you are confusing these with medications such as phenylephrine or oxymetazoline?  (which also, by the way, have not been shown to benefit the eustachian tube)

The common cold is transmitted by viruses, not congested mucosal surfaces.  No amount of congestion can create a cold if the virus isn't there in the first place!

While liberally recommending such drugs is likely not to cause any harm, they are also not likely to help and may (rarely) have untoward side effects or, at least, cost patients additional money.  So, perhaps it's nitpicking to belabor this point, but as professionals, I think we should be held to a higher standard.

Cheers and thanks for offering your advice!

[OHNS2010]

Hi ENTMD,

I do welcome the comments made by you regarding the way I am advising the patients. I have a strong feeling that you are very much upset regarding prescribing of antihistaminics by me. Well, I take all the privilege to convince you.

1. First case:
Regarding suspected Eustachian tube dysfunction. I hope you have not gone through the history given by that patient thoroughly. He mentions his symptoms have subsided with the use of steroid nasal spray so I think it is wise to administer antihistaminics as they reduce the nasal as well as congestion around the opening of the Eustachian tube and reduce the symptoms further more. I particularly advice fexofenadine as it is less sedative compared to other antihistaminics.

2. Second Case:
Regarding perforation of the tympanic membrane following baro-trauma. The patient has complained of blood spots in the sputum, it is unlikely that it can come from the Eustachian tube as it is already blocked due to pressure variation and the patient is having bleeding from the ear. The blood spots in the sputum might be secondary to the sub-mucosal bleed from the paranasal sinuses (commonly from the frontal sinuses) following the incident of diving. So there are always some remote chances that he might acquire common cold, hence I wanted him to take antihistaminics empherically, to reduce the congestion of the nose and also the opening of the Eustachian tube. Prevention is better than cure. In fact I forgot to advise antibiotics also, as in case if the water is infected there are chances that he might develop an ear infection, furthermore the healing of the perforated drum might be delayed.

If you are still not convinced you can go through the links I have given below. I always look forward for your suggestions so that even my knowledge can be improved. I would also bring to your kind notice that till now I have answered the questions responsibly keeping into mind ethics, advancements and practical aspects, as it is viewed by a large number of people. Medicine is an ocean and our knowledge and experiences is just a pail of water and controversies always prevail.

1. http://im.unboundmedicine.com/medicine/ub/view/5-Minute-Clinical-Consult/116831/all/Eustachian_Tube_Disorder
2. http://books.google.mv/books?id=4qkktBsVsGoC&pg=PA121&lpg=PA121&dq=Role+of+antihistaminics+in+Eustachian+tube+dysfunction&source=bl&ots=l85sokOHql&sig=QPlyDpVaWnHi118QU-gfJMybCs8&hl=en&ei=SowWTMvpAcL6lwfIhODhDA&sa=X&oi=book_result&ct=result&resnum=5&ved=0CB8Q6AEwBDgU#v=onepage&q&f=false
3. http://scuba-doc.com/Midearbt.html
4. http://www.patient.co.uk/health/Eustachian-Tube-Dysfunction.htm
5. http://www.bcm.edu/oto/jsolab/eust_tub.htm
6. http://www.dizziness-and-balance.com/disorders/symptoms/etdysfunction.htm
7. http://books.google.mv/books?id=Qcxg1OCHg3oC&pg=PA620&lpg=PA620&dq=Role+of+antihistaminics+in+Eustachian+tube+dysfunction&source=bl&ots=Xb1Ty5ab0N&sig=cUSMXciXemSCdhjmC-z_aocAc7c&hl=en&ei=t4cWTP-wBYW0lQfmsY3_Cw&sa=X&oi=book_result&ct=result&resnum=8&ved=0CDMQ6AEwBw#v=onepage&q&f=false
8. http://www.empowher.com/media/reference/eustachian-tube-dysfunction
9. http://en.wikipedia.org/wiki/Aerosinusitis
10. http://www.nlm.nih.gov/medlineplus/ency/article/001064.htm
11. http://docs.google.com/viewer?a=v&q=cache:WQsaZEY1UMIJ:www.crcnetbase.com/doi/pdf/10.1201/9781420015478.ch28+antihistaminics+in+the+treatment+of+traumatic+tympanic+membrane+perforations&hl=en&gl=mv&pid=bl&srcid=ADGEESiyl3r6G1gifB9kDH0GXmWRuLt_0vQ9XYArFAFF2mVy_o_kdlvlGCri5Z9MXWAxRM-qx9Erkr2_zxDLcG3zi5LrSt2CrLhBFCFvYfYR7vQNj0m2tabsCC2C3sDljITRYSB-87M4&sig=AHIEtbSd4HM4G8bumP-iraNRXmgNcwJoZQ

[ENTMD]

I would ignore all of that stuff about antihistamines.  Nonsense.  They will not prevent "you from getting cold", "delay the healing" and have no role whatsoever in "decongestion". You don't need them.

[OHNS2010]

Hi,

    Baro-trauma (ruptured ear drum) occurs because of sudden change in the pressure, so in this case you need not worry too much as traumatic perforation heals by itself.  Spitting of the blood clots is because of the sub mucosal bleeding in the para nasal sinuses.
  
    Just avoid instilling any ear drops or allowing water into the affected ear, also take some antihistaminics (cetrizine/fexofenadine) to prevent you from getting cold as this will further delay the healing of the ear drum, apart from this it also helps in reducing the edema by the process of decongestion.

Regards
OHNS2010

[ENTMD]

A ruptured ear drum in and of itself is not the worst thing that could happen; these will generally heal up just fine on their own.  Hearing loss, temporarily, is also present with this.  Worse is if he also has severe dizziness, this may indicate that there was an inner ear rupture as well.  If this is the case, see an ENT specialist immediately.

Blood could have come down the Eustachian tube and be the source.